Respiratory Therapy Consult Service Handbook 2012

Respiratory
Therapy
Consult Service
Handbook 2012
1
Respiratory
Therapy
Consult Service
Handbook 2012
Respiratory Therapy Consult Service
A survey conducted at Cleveland Clinic in 1987 demonstrated that
approximately 25% of Respiratory Therapy treatments were ordered
inappropriately, that is, either there were no indications for therapy
or the wrong therapy was selected. In an attempt to remedy this
situation and improve patient care, the Respiratory Therapy Consult
Service has been created to assist the physician with evaluating
patients’ respiratory care needs, determining the indications for
respiratory therapy, and selecting the appropriate modalities.
This booklet is designed to inform you about the procedure for ordering a Respiratory Therapy Consult, the process (algorithms) used to
determine specific therapies, and the evaluation process. If you have
any questions regarding this service please feel free to ask any of
the therapists or call Respiratory Therapy at 45797 and talk with a
Supervisor or the Education Coordinator.
Table of Contents
Ordering a Respiratory Therapy Consult
1
Care Plan Process2
Patient Evaluation Form3
Predicted Minimal Vital Capacities
4
Indication Guidelines for Respiratory Therapy Modalities
5, 6
Standard Treatment Frequencies
7, 8
Care Plan Form9
Common Respiratory Therapy Medication Guidelines
10
Algorithms for Respiratory Therapy Treatment Modalities
11-20
ICU Algorithms
Ventilator Management21
Ventilator Weaning22, 23
Noninvasive Positive Pressure Breathing (NIPPV)
25, 26
Home Oxygen Qualification
26, 27
New Evaluations
A.
B.
C.
A physician may write an order for a Respiratory Therapy
Consult by:
1. Using the Computer Physician Order Entry (CPOE) system
(indications for therapy should be included)
Respiratory Therapy Consults are provided for all patients for
whom respiratory therapy consult orders are written with the
exceptions of:
1. Pediatric Patients
2. Patients admitted to the short stay unit, unless they are
admitted to the hospital.
When a physician writes an order for a Respiratory
Therapy Consult:
1. An evaluation will be performed according to the
Respiratory Therapy Consult Service (RTCS) standardized
evaluation guidelines and a care plan documented.
2. Discussion between the physician and a Respiratory
Therapist concerning the rationale for therapy is encouraged.
3. The RTCS care plan (which will include physician
orders for specific medications) will be followed until the
indications for therapy are resolved.
4. During the course of therapy, the physician will be notified
if the patient’s clinical status worsens, or if an adverse
event occurs.
5. Physician written medication orders will be followed for
24 hours and the patient reassessed. If therapy is not
indicated at this time, the physician will be notified to
discontinue treatment.
6. Short-term orders (orders <24 hour duration) for a single
modality (e.g., oxygen, aerosol) will be followed without
generating a Respiratory Therapy Consult Service (RTCS)
evaluation.
For questions: Please PAGE #23406 or call ext. 45797
1
Re-Evaluations
A.
B.
Daily assessment will be made by the Therapist treating the
patient and if changes are indicated, they will be presented
during Consult Rounds with a Supervisor or a Clinical
Specialist. If the changes are in accordance with the Consult
Service guidelines/algorithms, they will be instituted at this time.
Changes will be recorded in our management information
system (MediServe) and will be available for review in the
hospital EPIC system.
Care Plan Process
STEP I
Perform patient evaluation using evaluation guidelines.
Determine appropriate Triage number.
STEP II Determine indications and related therapy using indication
guideline sheet.
STEP III Follow appropriate therapy flow sheet (algorithm):
a.aerosol therapy
b.hyperinflation
c.bronchopulmonary hygiene
d.oxygen therapy
STEP IV Write care plan to include:
a.therapy
b.frequency
c.indications
2
Respiratory Therapy Evaluation
Name ____________________________ Med Record # ________________ Date _______________
Time _____________ Age __________ Height _________ Diagnosis ___________________________
CHART REVIEW
Clinical Finding
0
1
2
Pulmonary Status
(-) History
(-) Smoking
Smoking
history
<1 pk a day
Smoking
history
1 pk a day
Surgical Status
No surgery
General
surgery
Lower
abdominal
Chest x-ray
Clear
Unavailable
Lab Results
Vital signs
Infiltrates,
atelectasis,
or pleural
effusion
PaO2
3
Pulmomary
impairment
acute or
chronic
Thoracic
or upper
abdominal
4
Points
Severe or chronic
with exacerbation
Thoracic with
pulmonary
disease
Infiltrates in
Infiltrate +
more than atelectasis and/or
one lobe
pleural effusion
Date
PH
PaCO2
HCO3
SaO2/FIO2
SaO2/FIO2
WBC
Hb
Platelet Ct.
HR_____RR_____BP_____ Min. Pred. VC ______ Actual VC ______
TEMP (F)
Peak Flow ______
PATIENT ASSESSMENT
Points
0
1
2
3
4
Points
Dyspnea on
Use of accessory
Severe S.O.B.
Respiratory
Increased
exertion, irregular muscles, pro- accessory muscle
Pattern
RR 21-25
pattern RR
longed expiration
use
26-30
RR 31-35
RR >35
Alert,
Lethargic,
Confused, does
Mental Status
oriented,
follows com- not follow comObtunded
Comatose
cooperative
mands
mands
Decreased
Decreased
Crackles in the Wheezing and or
Breath Sound
Clear
unilaterally
bilaterally
base
rhonchi
Strong,
No spont. cough
Strong,
Weak, nonCough
spontaneous,
Weak, productive
may require
productive
productive
non-prod.
suction
Ambulatory w/ Temporarily Non Bed rest, able to Bed rest, unable
Level of activity Ambulatory
assistance
ambulatory
position self
to position self
Oxygen
1-3 Liters
4-6 Liters
>50%
required for
No Oxygen
100%
(25%-35%) (>35%-<50%)
<100%
Sp02≥ 92%
Non-invasive
Continuous
Ventilation No ventilatory
Nocturnal
ventilation,
mechanical
Status
assist
CPAP/BiPAP
High flow nasal
ventilation
cannula
Regular
pattern
RR 12-20
Predicted Ideal Body Weight (kg)
(males: 50 + (2.54 x inches >60)
(females: 45 + (2.54 x inches >60)
Multiply ideal body weight x 15 cc for minimal pred. VC
Triage 1
>24
Triage 2
(20-24)
Triage 3
(13-19)
Triage 4
(7-12)
Triage 5
(0-6)
3
TOTAL POINTS
TRIAGE SCORE
Predicted Minimum Vital Capacities
HGT
4´9˝
4´10˝
4´11˝
5´0˝
5´1˝
5´2˝
5´3˝
5´4˝
5´5˝
5´6˝
5´7˝
5´8˝
5´9˝
5´10˝
5´11˝
6´0˝
HGT
5´5˝
5´6˝
5´7˝
5´8˝
5´9˝
5´10˝
5´11˝
6´0˝
6´1˝
6´2˝
6´3˝
6´4˝
6´5˝
6´6˝
6´7˝
6´8˝
Women
IBW Kg
38
40.4
42.6
45
47.4
49.8
52.2
54.6
57
59.4
61.8
64.2
66.6
70
72.4
74.8
Men
IBW
62
64.4
66.8
69.2
71.6
74
76.4
78.8
81.2
83.6
86
88.4
90.8
93.2
95.6
98
4
PRED L
.570
.606
.639
.675
.711
.747
.783
.819
.855
.891
.927
.963
.999
1.05
1.08
1.12
PRED
.930
.968
1.00
1.03
1.07
1.11
1.14
1.18
1.22
1.25
1.29
1.32
1.36
1.40
1.43
1.47
Indication Guidelines
Indications
A.
Aerosol Therapy
1. bronchospasm (bronchodilator)
2. history of bronchospasm (beta agonist, anti-cholinergic,
steroid)
3. home regimen
4. physician order
5. proteinaceous secretions (mucolytic)
6. inflammation, mucosal edema (steroid, vasoconstrictor)
B. Bronchopulmonary Hygiene
1. productive cough
2. history of mucus producing disease
3. rhonchi on auscultation
4. patient is unable to deep breathe and cough spontaneously
C.
Hyperinflation Therapy
1. atelectasis
2. upper abdominal or thoracic surgery, or COPD & surgery
3. restrictive disease associated with quadriplegia and, or
dysfunctional diaphragm
D. Oxygen Therapy
1. PaO2 < 65 torr on room air
2. SpO2 < 92% on room air
3. clinical signs of hypoxemia*
4. chest pain with cardiac history
5. home O2
6. post-op care
7. O2 requirement > 6 lpm, patient unable to tolerate a mask
— high flow nasal cannula indicated.
*Increased respiratory rate, increased pulse rate, diaphoresis,
confusion, cyanosis
5
E.
Respiratory Monitoring
1. Pulse Oximetry
a. O2 titration
b. PRN treatment order
c. unstable respiratory status
2. ABGs (SpO2 <92% on room air or 4 lpm O2 )
a. SpO2 < 92% RA
b. SpO2 < 92% on > 4 lpm
3. Continuous pulse oximetery
a. tracheal decannulation (continuous pulse oximetry for
12 hours)
b. non-invasive ventilation (NPPV)
c. ICU patients
F.
Suctioning
1. presence of copious secretions not cleared by cough
2. patient unable to cough
3. artificial airway
G. CPAP
1. oxygen desaturation
2. atelectasis
3. obstructive sleep apnea (OSA)
H. BiPAP
1. augment ventilation
a. neuromuscular disease
b. diaphragmatic paralysis
c. central hypoventilation
d. severe OSA
I.
Flolan (epoprostenol)
1. severe pulmonary hypertension
2. cardiac assist device surgery with ® ventricular dysfunction
3. severe hypoxemia (PaO2 /FiO2 <200 mmHg)
NOTE: For acute symptoms of hypoxemia or bronchospasm
associated with tachycardia, tachypnea, or decreased oxygen
saturation, treat the patient with the appropriate oxygen device
or a bronchodilator via a SVN first, before completing the entire
evaluation process. Bronchodilators may be given q2-q4, ATC and
PRN x 24 hours until symptoms subside. In such an acute situation,
any immediate physician orders will be followed until a complete
RTCS evaluation has been made.
6
Frequencies Guidelines
A.
Bronchopulmonary Hygiene
1. Q4 ATC
Copious secretions,
SOB, unable to sleep,
suspect mucus plug
2. QID & PRN at night Moderate amounts of secretions
3. TID
Small amounts of secretions + poor cough,
history of secretions
4. Q shift WA
Patient unable to deep breathe & cough
spontaneously
B. Hyperinflation Techniques**
1. Q4 WA & PRN Patients with severe atelectasis, + low PaO2
2. QID
Patients at high risk for,
or with persistent atelectasis
3. TID
Patients at risk for developing
atelectasis
4. Q shift, WA
Prevention of atelectasis
5. Instruct, D/C
Patients able to perform
well on their own
C.
1
2
3
4
1
2
3
4
5
Pulse Oximetry ***
1. Continuous until
Unstable patients, 1
stable then Q4 + continuous NPPV
PRN in between
2. QID, + PRN in Low PaO2 with variances
2
between
3. PRN
To titrate FiO2
3, 4, or 5
4. Daily x 2 days
If, after titration, 4 or 5
SpO2 remains at least
92%, D/C pulse oximetry
(Continued on page 8)
7
D. (Respiratory Monitoring) and E. (Suctioning) are performed PRN
Note: *If patient requires more frequent aerosols, please contact
supervisor or work leader.
**IS and PEP must be performed by patient on their own Q 1 hr WA.
***Patients not on O2, with SpO2 > 92% should have pulse oximetry
DC’d and restarted only when clinical signs indicate a need for O2.
PRN orders (except for oximetry or suctioning) must always include
a frequency - e.g. Aerosol Q4 WA and PRN Q4
8
CLEVELAND CLINIC
DEPARTMENT OF PULMONARY DISEASE
RESPIRATORY THERAPY
CONSULT/EVALUATION
Your patient has been evaluated by the Respiratory
Therapy Consult Service. Based on the patient’s
clinical indicators, the Care Plan designated
below will be implemented.
Date of Evaluation_____/_____/_____ Allergies____________________________________________
Time of Evaluation ____:____
Diagnosis(es)___________________________________________
CLINICAL INDICATIONS
Aerosol
Therapy
Broncho/Pulm Hyperinflation
Hygiene
qatelectasis
q bronchospasm
qproductive cough
qhistory of bronchospasm qrhonchi on auscultation
qhome regimen qphysician order qhistory of mucous qproteinaceous prod. disease
secretions
qpatient unable q inflammation/ to deep breath mucosal and cough edemaedema
spontaneously
Oxygen
Therapy
qupper abdominal q SpO2 < 92% or thoracic or Pa02 <65 on room air torr
surgery, or COPD & surgery
qclinical signs of
Respiratory
Monitoring
qO2 titration
(pulse ox.)
qContinuous
pulse oximetry
(nstable resp.
status)
Suctioning
q presence of
secretions
q unable to cough effectively
hypoxemia
q artificial
qrestrictive disease associated with qchest pain
airway
quadraplegia and, with cardiac qABGs (SpO2< or dysfunctional history
92%on
room
diaphragm
air or 4 lpm O2)
q home 02
q post op care Oximetry Sat / FiO2 ________________
Vital Capacity _____________________
CARE PLAN
Aerosol TherapyFrequency
q DPI q Neb q MDI
q DPI q Neb q MDI
q DPI q Neb q MDI
Broncho/Pulmonary q pos. drainage
Hygiene
q percussion/vibration q coughing techniques
Hyperinflation
q incen. spiro.
q PAP device
Oxygen Therapy
q FiO2 % _____
q liters / minute _____ q Device _______
Monitoring
q pulse oximetry q ABGsq resp. mechanics
Suctioning
q nasal tracheal
q tracheal
Comments PRINT NAME: ______________________________________________________________________________________
SIGNATURE:____________________________________________________ BEEPER NO: _______________________
Care plan modifications, made in response to changes in the patients’ condition, are available for your review through
the computerized order entry system.
158974 Rev. 7/04
9
Common Respiratory Therapy
Medication Guidelines
MED NAME
Abelcet
Advair
Fluticasone/Salmeterol
Aerobid
Albuterol
Amphotericin
Atrovent
Azmacort
Colymycin
Combivent
Albuterol/Ipratropium
Cromolyn Sodium
Flovent
Foradil
Mucomyst
Pentamidine
Pulmicort
Pulmozyme
Qvar
Racemic Epinephrine
Ribavirin
Serevent
Spiriva (tiotropium)
Symbicort
Formoterol/Budesonide
Tobramycin
Ventavis
Xopenex
(see CCF pharmacy policy)
DELIVERY FORM*
SVN
DPI
(1 inhalation)
MDI
(2 puffs)
MDI
(2 puffs)
SVN
(unit dose)
MDI
(2 puffs)
SVN
SVN
(unit dose)
MDI
(2 puffs)
MDI
(2 puffs)
SVN
DOSAGE
50 mg
100/50, 200/50, 500/50 mcg
115/21, 230/21, 450’21 mcg
250 mcg
2.5 mg, 5.0 mg
90 mcg
10 mg, 40 mg
0.5 mg
17 mcg
100 mcg
75 mg, 150 mg
MDI
SVN
MDI
DPI
MDI
DPI
SVN
SVN
SVN
DPI
SVN
MDI
SVN
SPAG
DPI
DPI
(2 puffs)
(unit dose)
(2 puffs)
(I inhalation)
(2 puffs)
(1 inhalation)
103/16 mcg
20 mg
800 mg
50, 100, 500 mcg
44,110,220 mcg
12 mcg
10%, 20%
300 mg
0.25, 0.5, mg
90, 180 mcg
2.5 mg
40, 80 mcg
0.5 cc of 2.25% solution
6 grams
50 mcg
18 mcg
MDI
SVN
SVN
SVN
MDI
(2 puffs)
(unit dose)
(1 inhalation)
(2 puffs)
(1 inhalation)
(1 inhalation)
(unit dose)
(2 puffs)
80/4.5, 160/4.5 mcg
200, 300 mg
10, 20 mcg
0.63, 1.25 mg
45 mcg
* Delivery Device
SVN
MDI
DPI
SPAG
Small volume nebulizer
Metered dose inhaler
Dry powdered inhaler
Small particle aerosol generator
** Frequency table (from least frequent on left to most frequent)
PRN1
WA2
ATC3
1
As needed
Daily
Q shift
Q shift
2
While awake
BID
Q 6 hrs
Q 6 hrs
3
TID
Q 4 hrs
Q 4 hrs
Around the clock
10
QID
Q 2 hrs
Q 2 hrs
Aerosol Therapy*
Indications:
Current, or history of bronchospasm
Inflammation, mucosal edema
Proteinaceous secretions
Type of Medication:
Bronchodilator
Steroid, vasoconstrictor
Mucolytic
Patient alert?
No
No
Small
volume
nebulizer
with mask
Yes
Yes
Shallow
breathing?
Can patient
take a deep
breath?
Yes
PAP device**
with mask
VC >
minimal
predicted?
No
PAP device**
with mouthpiece
Yes
MDI criterial
met?
No
*Physician must be notified prior
to discontinuing medications.
Small volume
nebulizer with
mouthpiece
• Bronchodilators – If the patient lacks
a prior history of lung disease, is not
using bronchodilators at home, and
has no wheezing when receiving the
bronchodilator less often that q 4 hours,
the bronchodilator may be discontinued.
• Acetylcysteine – If secretions have
lessened to the point that the patient
is able to clear them with a cough, the
mucolytic may be discontinued.
• Anti-inflammatory Medications – If
the patient lacks any prior history of
lung disease, is not using and inhaled
anti-inflammatory medication at home,
and lacks wheezing by examination or
by history for at least 24 hours, the
anti-inflammatory medication may be
discontinued.
(Discontinuation requires a
physician order.)
Yes
MDI
with a
spacer
**Appropriate PAP devices:
• PEP (i.e. Thera-PEP)
• Measured PEP (i.e. EZ-PAP)
• Oscillatory device (i.e. Acapella)
• Intermittent CPAP
11
Bland Aerosol (Thick Secretions)
No
VC > minimal predicted?
Shallow breathing?
No
Continuous
by mask,
PRN suction
Yes
Patient alert?
Yes
No
Continuous
by mask with
PAP device
treatments,
PRN suction
Oscillatory
PAP device
before bph
**Appropriate PAP devices:
• PEP (i.e. Thera-PEP)
• Measured PEP (i.e. EZ-PAP)
• Oscillatory device (i.e. Acapella)
• Intermittent CPAP
12
Yes
20 minutes
by mask
before bph
Suggestions for Asthma Medications
No
Is patient
on therapy
at home?
Yes
Follow
home
regimen
Is the patient
admitted for asthma
exacerbation?
Is patient symptomatic?**
No
Continue inhaled
steroid if patient uses it
at home
Yes
Albuterol
PRN QID
Does patient require
treatments > QID?
Does
patient
demonstrate
proper MDI
technique?
Reinstruct
or change
SVN
Albuterol*
4 puffs
QID - Q4
No
No therapy
needed
No
Yes
Yes
No
Add: steroid
Yes
Continue
MDI
therapy
Continue therapy
x 24 hrs. then
reassess***
Is patient still
symptomatic**?
Yes
No
Notify physician
Continue therapy
All medications require a physician order for the drug, dose and frequency
* Albuterol may be given up to every 1-2 hours if needed. If the patient is
unable to use an MDI effectively, use a small volume nebulizer.
** Symptomatic = wheezing, SOB, cough, exercise intolerance, RR > 21.
*** If wheezing subsides and respiratory rate is < 21, decrease Albuterol to
2 puffs QID.
13
Guidelines for Priming Metered Dose
Inhalers (MDIs)
Proventil HFA (albuterol)
ProAir HFA (albuterol)
Ventolin HFA (albuterol)
Atrovent HFA (ipratropium)
Flovent HFA (fluticasone)
Advair HFA
(fluticasone/salmeterol)
Xopenex HFA (levalbuterol)
Symbicort
(formoterol/budesonide)
Qvar HFA (beclomethasone)
Combivent
(ipratropium/albuterol)
Azmacort (triamcinolone)
Maxair (pirbuterol)
Alvesco (ciclesonide)
Aerospan HFA (flunisolide)
# OF
SPRAYS
WHEN TO REPRIME
TO
PRIME
4
after 2 wks of no use
3
after 2 wks of no use
4
2
4
4
4
2
after 2 wks of no use, or if dropped
after 3 days of no use
after 7 days of no use, or if dropped
after 4 wks of no use, if dropped
only 2 sprays to reprime
after 3 days of no use
after 7 days of no use, or if dropped
2
3
after 7 days of no use
after 24 hrs of no use
2
2
3
2
after
after
after
after
14
3 days of no use
48 hrs of no use
10 days of no use
2 wks of no use
RECOMMENDED INSTRUCTIONS FOR DRY
POWDERED INHALER USE
Pulmicort Flexhaler – (budesonide)
Must be primed before 1st use. To prime, twist the brown grip in
one direction & fully back in the opposite direction. Repeat once
more. When loading a dose, flexhaler must be in the upright position
(mouthpiece up).
Spiriva – (tiotropium)
Do not press green piercing button more than once. Pierce with
mouthpiece pointing up. Breathe in medication with the handihaler
in the horizontal position.
Asmanex – (mometasone)
No need to prime it. Hold inhaler in the upright (pink on bottom)
position, twist cap off in counterclockwise direction. Inhale medication
with inhaler in the horizontal position. Cap must be replaced to load
the next dose. Cap will not come off if medication is gone.
Advair (fluticasone/salmeterol), Flovent (fluticasone), Serevent
(salmeterol) (Diskus) –
Place Diskus in horizontal position. Slide lever away until it clicks.
Inhale the medication with the Diskus in the horizontal position.
Tilting the Diskus will cause the medication to fall out. (the patient
will not get any medication)
Foradil – (formoterol)
Hold Aerolizer in the upright position. Push both buttons at the same
time and only once. With the buttons facing left and right and the
aerolizer in the horizontal position, inhale medication.
15
Bronchopulmonary Hygiene (bph)
Productive Cough
No
Yes
Copious secretions?
(> 30 cc per day)
Strong cough?
Strong cough?
No
Yes
Percussion,
vibration,
suction
PRN**
No
instruct
deep
breathing
and cough
Yes
Postural drainage,
percussion,
vibration*,
suction PRN**
bhp will be discontinued when
secretions are no longer present (for 2
consecutive scheduled treatments) or
when secretions and/or rhonchi can be
cleared with cough.
Do rhonchi
persist after
patient
coughs?
No
Yes
Instruct deep
breathing and
cough
Percussion,
vibration*,
deep breath
and cough
Non-Productive Cough
Rhonchi?
No
History of mucus
producing disease?
No
Yes
Yes
Is patient able to deep
breathe and cough
spontaneously?
No additional
therapy needed
No
Yes
No
Effective cough
and rhonchi clear
with cough?
Percussion,
vibration*,
suction PRN**
Strong cough?
No
Percussion, vibration*, and
suction** x24 hrs; then reassess
Percussion,
vibration*, deep
breath and cough
suction PRN**
Yes
Instruct deep
breathing and
cough
Yes
Instruct deep
breathing and cough
* Oscillatory device
** Do not perform nasotracheal suctioning on a patient with a platelet count
< 50,000 or neutropenia.
16
Lung Expansion Therapy
Indications:
1.Atelectasis
2.Upper abdominal or thoracic surgery, or COPD and surgery
3.Restrictive disease associated with quadriplegia or dysfunctional
diaphragmn
No
No
Emerging
from
anesthesia or
sedation?
BS clear and RR ≤28
and RA Sp02 ≥92%
ALERT
PATIENT?
No
Yes
Defer eval to
next shift
Yes
Yes
Can patient
perform a VC
maneuver?
BS clear &
RR < 28 &
RA Sp02 ≥92%
Yes
Is VC > minimal
predicted?
No
Yes
No
No
Yes
Yes
Defer PAP
therapy; reassess
in 24 hrs.
Persistant
atelectasis?
No
CPAP or
appropriate
PAP device*
Appropriate PAP
device*
Defer PAP therapy;
reassess in 24 hr.
Incentive
spirometry,
therapist
follow-up
*Appropriate PAP devices:
• PEP (i.e. Thera-PEP)
• Measured PEP (i.e. EZ-PAP)
• Oscillatory device (i.e. Acapella)
• Intermittent CPAP
Hyperinflation therapy will be discontinued when atelectasis has
been resolved as evidences by chest x-ray, and/or when the patient’s
SpO2 and respiratory rate return to normal (SpO2 ≥92% on room
air) or baseline values for 2 consecutive treatments and breath
sounds are clear.
17
Oxygen Therapy
Indications:
• Pa02 < 65 on RA
• Sp02 < 92% on RA
• Clinical signs*
ABG
available?
Yes
No
Yes
Pa02 < 65 mmHg
on room air?
Chest pain
and cardiac
history?
Yes
No
Use 02
device
appropriate
for degree
of distress
Continue
current
02 3
Pa02 < 92% on room
air 02 > 4 Lpm2, (no
ABG available)?
Yes
No
Check
Sp02, use
appropriate
02 device
Does
Sp02
correlate
with ABG
sat?1
No
Yes
Repeat
ABG after
instituting
02 therapy
Check
Sp02 after
instituting
02 therapy
Check
ABG,**
then use
appropriate
02 device
Does
Sp02
correlate
with ABG
sat?1
No
Repeat
ABG after
instituting
02 therapy
Clinical
signs* of
hypoxemia?
No
Yes
Yes
Repeat
Sp02 after
instituting
02
therapy
No
* SOB, tachycardia, diaphoresis, confusion, chest pain, cardiac Hx.
** If patient’s platelet count is <50,000 notify the physician before
the ABG draw.
*** See RT 02 procedure #704
1.
2.
3.
Positive correlation exists if Sa02 & Sp02 demonstrate ± 3%
agreement within the 90% to 100% range. If either Sp02 or
Sa02 is less than 90%, titrate therapy using Sa02. (May use
Sp02 if Sa02 = Sp02).
Patients on less than 4 Lpm, 02, increase 02 as needed to
achieve a Sp02 ≥ 92% (max. 4Lpm). If patient requires > 4
Lpm, go to Yes in this portion of algorithm and check on ABG.
Or no 02 if saturation is adequate on room air.
Note: Patient’s that require greater than 6 Lpm O2 on a nasal cannula
and cannot tolerate a mask, will be put on a high flow nasal cannula
18
Continue
current
02 3
Use 02 device
appropriate
for degree of
distress, then
check ABG***
Does
Sp02
correlate
with ABG
sat?1
Yes
Check
Sp02 after
instituting
02 therapy
Titrating Oxygen Therapy for Discontinuation
Does patient have
clinical signs of
hypoxemia? 1
Yes
No
Delay O2
titration, see
O2 algorithm
No
Is patient’s SpO2 or
SaO2 ≥ 92%? 2
Yes
Is SpO2 < 92%
Yes
No
 O2 to
achieve an
SpO2 ≥ 92%.
Re-check 3
Continue
present O2
therapy
 O2 to
maintain SpO2
≥ 92%. Recheck 3
Does patient
require O2 to
maintain SpO2
≥ 92%
Yes
Check SpO2
on next shift
(while awake)
1.
2.
3.
SOB, tachycardia,
diaphoresis, confusion.
SpO2, criteria may be
modified with documented
evidence of pre-exsisting
chronic hypoxemia.
Appropriate time lapse for
recheck:
10 minutes for patients
without pulmonary history
20 minutes for patients
with a pulmonary history
No
Re-start O2
Maintain SpO2
≥ 92%
Re-check 3
Note: O2 concentration should
not be decreased more than
once per shift.
19
No
Is SpO2 >
92% on
room air?
No
Re-check
on next shift
(while awake)
Is SpO2 ≥
92% on
room air?
Yes
D/C O2
Yes
D/C
Arterial Blood Gas Monitoring
Standard ABG Criteria
•
•
•
•
•
•
•
•
•
•
•
•
New admission with no prior baseline data*
Initiation of HFO or APRV
Initiation of nitric oxide (obtain ABG Q 6hr during treatment)
Sepsis management (obtain 2 ABG samples Q 4hr for lactate)
pH <7.28 or >7.50
Cyanaosis
Unexpected dysrhythmias
Unexpected change in mental status
Unexpected respiratory rate <8 or >32 for >5 min, or
paradoxical breathing
Acute change in breath sounds
Acute onset of hemodynamic instability
Non-intubated patient with nasal cannula O2 > 4 L/min
or mask >35%
Evaluate patient
Standard ABG
criteria met
Yes
No
Mechanical
ventilation
Yes
No
Monitor Sp02
Yes
Reliable Sp02
data available
Minute
ventilation
setting
change
Yes
No
* All ReSCU patients require an ABG on admission
20
Draw ABG sample
21
1. Considerations for
Ventilatory Assistance
• Tachypnea/bradypnea
• Increasing oxygen need
• Increasing PaCO2
• Altered mental status
Initial
Assessment
2. Considerations for Non
invasive Ventilation
• COPD with initial
respiratory failure
• Congestive heart failure
3. Criteria to Pass Wean Screen
• Reversal of underlying causes
• Presence of spontaneous
breaths
• PaO2 > 60 torr or SaO2 >
90% on FiO2 ≤ 40%
• pH > 7.30
• PEEP ≤ 8 cm H2O
• RR < 35 bpm
• Not in shock requiring high
dose vasopressons
All criteria must be met to pass
Yes
Extubate
Notify fellow
Yes
6
Pass
Extubation
Screen?
No
Consider
tracheostomy
6. Criteria for Extubation
• Suctioning less frequently
than Q2 hourly
• Adequate cough
• Follows commands (eg
5. Criteria to pass SBT
“close eyes”)
• RR < 40 bpm for > 50 minutes
All criteria must be met
• Systolic BP > 90 torr
to pass
Both criteria must be met to pass
5
Pass SBT?
No
Consider
gradual wean
4. Conditions for SBT
• PEEP ≈ 5 cm H2O
• Pressure support ≈ 5 cm H2O
• Trial to last 60 minutes
4
Perform SBT
Perform daily
wean screen
3
Pass Wean
Screen?
Consider
noninvasive
ventilation
Select mode
of ventilation
Reassess as
needed
Yes
Yes
2
Intubate?
Trached?
No
Yes
No
Reassess Q 24 hours
No
1
Need to
Ventilate?
Ventilator Management Algorithm
NIPPV (BiPAP) Therapy Assessment
and Management
Indications:
• Thoracic cage deformities
• Neuromuscular disease
• Idiopathic hypoventilation
• Respiratory distress
• Hypercapnic COPD
• Obstructive sleep apnea
• Obesity hypoventilation
Exclusion Criteria:
• Respiratory arrest
• Cardiorespiratory instability
• Uncooperative patient
• Recent facial, esophageal, or
gastric surgery
• High aspiration risk
• Inability to protect airway
• Fixed anatomic abnormalities
of the nasopharynx
• Copious secretions
Assessment:
1. Cause of respiratory distress
2. Hemodynamically stable
(systolic >90 mmHg)
3. pH ≥ 7.28
4. Assess level of consciousness
5. Protect airway
6. Secretions
Critical Factors for Success of
NIPPV:
1. Cooperative patient
2. Hemodynamically stable
3. Ability to protect the airway
4. No excessive secretions
Advantages of NIPPV:
1. Patient comfort
2. Airway defense maintained
3. Ability to eat and speak
4. Endotracheal intubation
complications avoided
5. Lower risk of nosocomial
pneumonia
Disadvantages of NIPPV:
1. Need cooperative patient
2. Inability to suction airway
3. Facial trauma
4. Gastric distention
22
NIPPV (BiPAP) Therapy Management
See NIPPV (BiPAP)
Therapy Assessment
and Management
algorithm
NIPPV
indicated
Initial settings:
Mode: Spont/Timed
IPAP: 10-15cm H20
EPAP: 5-7cm H20
FiO2 to achieve SaO2
≥ 92%
Increase O2
appropriate
for degree of
distress
Clinical signs
of hypoxia?
Re-evaluate ABGs
in 1-2 hours.
No
Is PaO2 > 60
torr or SaO2 >
82%?
Yes
Yes
Recheck
Yes Does patient
SaO2 in
require O2 to
4 hours
maintain SaO2
≥ 92%?
No
Is SaO2 ≥ 92%
on room air?
Yes
D/C O2
Is PaCO2 and pH
When NIPPV as
Yes
improving?
appropriate.
Decrease
O2 to
maintain
SaO2 ≥
92%
Consult
physician
immediately.
Is pH > 7.28?
Consider
transfer to ICU
No
Yes
ASAP.
No
Is an uncompensated or
partially compensated
respiratory acidosis present?
Yes
Increase settings to deliver
more minute ventilation.
Increase IPAP or increase
mandatory respiratory rate.
23
Yes
Consider
other
therapy.
General Weaning Protocol
*Weaning Start Criteria:
• Presence of spontaneous breathing
• FiO2 ≤ 0.40
• pH > 7.30
• PEEP ≤ 8 cmH2O
• Respiratory rate ≤ 35/min
• Hemodynamically stable
Presence of all criteria required to pass
Assess patient
Weaning Stop Criteria:
• SaO2 < 90%
• PaCO2 increase > 8 mmHg
• pH < 7.30
• Respiratory rate > 35 breaths/min
• Heart rate > 120 beats/min
• Systolic blood pressure < 90 or > 160 mmHg
Weaning
criteria met*
Reassess
4-6 hours
Yes
Use Pressure
Support Algorithm
SmartCare
available
No
Yes
Start SmartCare mode
Set Night Reset option to activate
between 10 p.m. and 6 a.m.
Set Automatic Tube Compensation 100%
-set apnea delay to 60 seconds
Decrease PEEP
to 5 cmH2O
Decrease FiO2
by 0.10
No
Reassess in
24 hours
Yes
Yes
FiO2
> 0.30
Reassess
Q 2 hours
No
PEEP
> 5 cmH2O
Any
weaning
stop
criteria
met
Yes
Stop
weaning, Start
CMV+AutoFlow
or VC+A/C
No
*Trach Collar Procedure:
• Reassess Q 2 hours
• Stop if RR > 35/min or dyspneic
• If stopped, rest on PS 15 cmH2O
• Try trach collar again 4-6 hours
First day: continue 8 hours as tolerated
Second day: continue 16 hours
Third day: continue 24 hours with end
tidal PCO2 check Q 4 hrs
Rest on full support when not on
trach collar
No
24
vent
message:
Consider
Separation
Yes
Stop ventilation
Start trach collar*
Pressure Support Weaning Protocol for ReSCU
*Weaning Start Criteria:
• Presence of spontaneous breathing
• FiO2 ≤ 0.40
• pH > 7.30
• PEEP ≤ 8 cmH2O
• Respiratory rate ≤ 35/min
• Hemodynamically stable
Presence of all criteria required to pass
Assess patient
Weaning Stop Criteria:
• SaO2 < 90%
• PaCO2 increase > 8 mmHg
• pH < 7.30
• Respiratory rate > 35 breaths/min
• Heart rate > 120 beats/min
• Systolic blood pressure < 90 or > 160 mmHg
Weaning
criteria met*
Reassess
4-6 hours
No
Yes
Start Pressure Support mode
Set Automatic Tube Compensation to 100%
Set Inspiratory Pressure to keep:
-respiratory rate 15-30 breaths/min
-tidal volume > 300 mL
-PetCO2 < 55 mmHg
Set Apnea Ventilation parameters
-set apnea delay to 60 seconds
rapid/shallow
breathing pattern
Increase PS by
3 cmH2O
Yes
f/VT >
105*
Decrease PS by
3 cmH2O
No
Decrease PEEP to
5 cmH2O
Decrease FiO2
by 0.10
No
Reassess in
24 hours
Yes
Yes
FiO2
> 0.30
Reassess
Q 2 hours
No
PEEP
> 5 cmH2O
Any
weaning
stop
criteria
met
Yes
Stop
weaning, Start
CMV+AutoFlow
or VC+A/C
No
*Trach Collar Procedure:
• Reassess Q 2 hours
• Stop if RR > 35/min or dyspneic
• If stopped, rest on PS 15 cmH2O
• Try trach collar again 4-6 hours
First day: continue 8 hours as tolerated
Second day: continue 16 hours
Third day: continue 24 hours with end
tidal PCO2 check Q 4 hrs
Rest on full support when not on
trach collar
No
25
PS = 5
cmH20
for > 1 hr
Yes
Stop ventilation
Start trach collar*
Home O2 Qualification
I.
Qualifying Conditions
A. Chronic Cardio – Pulmonary Diagnosis
1. Example: COPD/ Asthma/ Lung Cancer/IPF/CHF/
Pulmonary hypertension
B. Hypoxemia as defined by:
1. ABG results: PaO2 < 56 torr, and/or, SaO2 <89% on
room air.
2. Pulse oximetry results: SpO2 <89% on room air.
II. Medicare/Private Insurance Carrier
A. Home O2 qualification
1. SpO2, at rest, of <89%
a. always check more than one site
b. check a manual pulse
c. document on desaturation study form
2. ABG at rest with PaO2 of <56 torr and /or SaO2 of
<89% on room air
a. SpO2 may be used to determine O2 requirements
3. Either ABG or Pulse oximetry results may be used for
qualification
a. qualifying studies must be done within 48 hours of
discharge home
b. patients going to another facility after leaving the
hospital must be qualified for home oxygen at that
facility before discharge home.
B. Determining needed O2 requirement
1. Determine lowest O2 level that will maintain an SpO2 of
≥ 92% (not to exceed 94%) at rest.
2. Ambulate patient on resting O2 requirement for six
minutes or as tolerated.
a. SpO2 on exertion should be > 90%
b. document the SpO2, the required liter flow and the
distance traveled before desaturation.
c. also document the resting SpO2 on the liter flow
required to maintain an SpO2 of > 90% on
exertion
26
C. Exertional Home O2
1. Patients with a chronic pulmonary diagnosis whose
resting SpO2 is >88% but desaturate to < 89%
with exertion
2. A desaturation study is required
a. ambulate patient at a normal pace for six minutes
or as tolerated
3. Determine lowest O2 level required to maintain an
SpO2 of >88% to <93% with exertion
a. document exertional SpO2 and liter flow required
b. document a resting liter flow on the exertional
liter flow
III. Medicaid (Ohio Department of Welfare) Patients
A. Follow Medicare guidelines
IV. Documentation for all patients
A. Fill out Desaturation Study Form
a. white copy goes in patient’s chart
b. yellow copy goes to the department
c. document all patient education on this form
B. Follow Respiratory Therapy Section documentation
procedure
27
NOTES
28
NOTES
29
NOTES
30
© The Cleveland Clinic Foundation 1992-2012
All rights reserved.
PWO 3027 Rev. 1/12